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History Repeats Itself: The Relevance of Historical
Pandemics to the Medical School Curriculum
M Jones
1,2
, S Quenby
1,2
and J Odendaal
1,2
1
Division of Biomedical Sciences, Clinical Sciences Research Laboratories, Warwick Medical School,
University of Warwick, Coventry, UK.
2
University Hospitals Coventry & Warwickshire, Coventry, UK.
ABSTRACT
INTRODUCTION: The dramatic global impact of the coronavirus pandemic has increased consideration on epidemiological progressions of pan-
demics. Measures implemented to reduce viral transmission have been largely historical, comparable in nature with the 1918 and 2009 influenza
pandemics, demonstrating the importance of clinicians’awareness on historical pandemics. Despite this, literature suggests medical students’
knowledge on previous pandemics is poor.
OBJECTIVES: This study aims to gather stakeholder information from UK medical students on the importance of including the history of pan-
demics in the medical school curriculum.
METHODS: A cross-sectional cohort study conducted via a mixed question type online survey was distributed to all UK medical schools to
explore stakeholder views. Grounded theory emergent coding was used to generate themes to free-text answers and SPSS and Excel were
used to analyse quantitative data using pivot tables and Fishers exact tests.
RESULTS: Two hundred and forty-one students consented to take part from eight medical schools in the UK with 98% of these students com-
pleting the questionnaire. 34% of students reported having teaching on pandemics with 78% of students stating it would be beneficial. Knowledge
was poor with 5.7% of students achieving 100% on knowledge-based questions. 72% of students believed that learning about the history of medi-
cine would be beneficial with 87% of these students referring to ‘benefiting (the) future’in their answers. Additionally, 79% of students thought it
would be beneficial to learn about historical pandemics with reference to the current COVID-19 pandemic.
CONCLUSION: To date, this is the only UK based study assessing stakeholders’views on including the history of pandemics in the medical
school curriculum. Our findings demonstrate that medical students wish to have more historical content included in their degree to better prepare
tomorrow’s doctors for situations that may occur when history repeats itself.
KEYWORDS: medical education, pandemic influenza, curriculum
RECEIVED: July 6, 2023. ACCEPTED: October 8, 2023.
TYPE: Original Research Article
FUNDING: The authors received no financial support for the research, authorship, and/or
publication of this article.
DECLARATION OF CONFLICTING INTERESTS: The authors declared no potential conflicts
of interest with respect to the research, authorship, and/or publication of this article.
CORRESPONDING AUTHOR: M Jones, Division of Biomedical Sciences, Clinical Sciences
Research Laboratories, Warwick Medical School, University of Warwick, Coventry, United
Kingdom. Email: Molly.Jones17@nhs.net
Introduction
Historically, infectious disease has represented a stark mortality
burden. Although this has eased over time, infectious diseases
still accounted for 7% of deaths in 2017.
1
Interspersed across
history are waves of infectious pandemics such as the plague of
Justinian in the sixth century, the black death in the fourteenth
century, the 1918 H1N1 influenza pandemic, the 2009 influenza
pandemic and more recently COVID-19.
2-4
The 1918 Influenza
pandemic was the most severe pandemic to date, infecting a third
of the world’s population and killing an estimated 50 million
people worldwide, surpassing the number killed in the First
World War.
2
Nevertheless, the adage ‘history repeats itself’has
consistently proved its correctness. The present coronavirus pan-
demic led people to turn to previous pandemics for guidance.
5,6
Indeed, not only does the COVID-19 pandemic and 1918 influ-
enza pandemic follow similar epidemiologic curves but the epi-
demiological curves between the 2009 influenza pandemic and
the COVID-19 pandemic share similarities.
7,8
The spectre of pandemics has long haunted epidemiologists,
with an ever-increasing population density, the ability to travel
and climate change, leading to concerns about rapid and wide
transmissions - concerns that have been borne out in the
present coronavirus pandemic. On the other hand, advances
in technology since the 1918 H1N1 Influenza pandemic has
allowed us to learn more about the pathophysiology, epidemi-
ology, and potential treatment options of viruses such as
H1N1 Influenza.
5,9
Public health measures employed to reduce viral transmis-
sion have been largely historical in nature, with the 1918 pan-
demic guiding initial coronavirus contingency planning. Such
comparisons can be directly seen; in 1918 social distancing
was introduced, schools and cinemas were shut, and fines
were given out for not wearing protective clothing or bulk
buying food items.
10
Similarly, in 2009 measures, such as
school closures were implemented, aiming to reduce transmis-
sion but research suggested that these were implemented too
late.
11
In 2009 once schools reopened there was a large
second wave of cases particularly affecting children.
12
Similar
methods aiming to reduce levels of infection were implemented
again in 2020 when COVID-19 spread around the world and
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Journal of Medical Education and
Curricular Development
Volume 10: 1–12
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DOI: 10.1177/23821205231210629
like in 2009, the reopening of schools in September 2020
caused a significant increase in cases particularly affecting chil-
dren.
13
Not only was Covid-19 similar in epidemiology to the
1918 and 2009 influenza pandemics, but similarities were strik-
ing in the way that it affected patients and the proportion of
admissions to intensive care.
4
Thus, further highlighting the
importance of teaching and facilitating the understanding of
previous pandemics to future doctors.
Several studies have assessed medical students’understand-
ing of the H1N1 1918 Influenza pandemic and infection pre-
vention methods.
14,15
In 2007, a study carried out in Canada,
demonstrated students had gaps in their knowledge relating
to the 1918 Influenza pandemic. Additionally, 28% of students
incorrectly believed that antibiotics could treat viral infections
and 46.1% of students incorrectly identified the route of trans-
mission.
16
A similar study performed in China in 2017 found
less than 50% of students correctly answering questions on
transmission, influenza symptoms and high-risk groups.
17
These studies highlight the lack of knowledge on pandemics
among medical students and further demonstrate the need to
include teaching on historical pandemics in the medical
school curriculum.
The history of medicine provides an understanding and
context of where interventions have worked or errors
made.
18,19
These comparisons and their direct clinical implica-
tions between pandemics demonstrate the importance of clini-
cians’awareness of historical pandemics.
20
Doctors and
medical staff understandably play a huge role in pandemic
care. Questions have been raised since COVID-19 on how
much a failure to recognise and understand infection rates,
ICU admissions and fatalities based on previous pandemic
data led to an increased morbidity and mortality rate during
COVID-19.
21
If there was a greater understanding of pan-
demic epidemiology, infection rates and morbidity would less
potentially erroneous decisions have been made?
The H1N1 pandemic led to advances in infection preven-
tion and pandemic management. Inclusion of previous pan-
demic in medical education is important to facilitate the
understanding of pandemic management.
22
It also provides a
glimpse into the relevance of the history of medicine within
the modern medical school curriculum. The condensed
nature of many medical school programmes, particularly gradu-
ate entry programs in the United Kingdom (UK), means that
the curriculum included has to be both concise and fit with
the learning outcomes set by the General Medical Council.
23
The recent outbreak of COVID-19 has raised many questions
surrounding medical education, including what role medical
students should play in a pandemic and the effects of a pan-
demic on medical education (10-12).
To date, no study has assessed the knowledge of UK medical
students on the 1918 H1N1 Influenza pandemic or assessed
medical students’views on the inclusion of the history of
medical pandemics in the medical school curriculum. Given
the adage, history repeats itself, this project will assess knowl-
edge of UK medical students on pandemics and related infec-
tion control. Further objectives include to establish the
current level of teaching on the history of pandemics and
gather stakeholder opinions on the role of the medical history
of pandemics and the inclusion of other areas of the history
of medicine within the medical school curriculum.
Methods
Ethical approval
Ethical approval for completion of this study was gained from the
University of Warwick Biomedical and ScientificResearch
Ethics Committee (BSREC 154/19-20). Participation was vol-
untary and students were informed that responses would not be
used as part of their medical degree or influence the results of
their degree. Informed consent was gained at the time of
participation.
Study design
A cross-sectional national cohort study delivered via an online
survey.
Questionnaire design
A 21-item questionnaire was devised by the research team to
assess the role of medical history within the curriculum.
Questions comprised a mixture of styles including multiple
choice, open-ended text responses and 5-point Likert-type
questions. Questions were designed based on the study aims
to ensure capture of key information. The survey was created
based on previously published works in the topic area for con-
sistency and to improve comparability across literature.
16,17
The
questionnaire was, therefore, content validated through com-
parison with the previously published work.
16,17
Ensuring
alignment of published work allowed content validation via
proxy expert consensus, it additionally ensured comparability
across the literature on the topic. In order to assess question-
naire reliability Cronbach’s alpha value was calculated for the
survey. Cronbach’s alpha value for the 2 5-point Likert-type
questions was 0.76 (questions 11 and 12 in the Supplemental
Material –Table 1 Copy of Questionnaire). Cronbach’s alpha
was also calculated for the multiple-choice questions –(ques-
tions 6,7,8 and 9 in the Supplemental Material –Table 1
Copy of Questionnaire) and was 0.33. Note this increased
with item deletion: 0.44 if question 6 was deleted, 0.74 if ques-
tion 7 was deleted, 0.69 if question 8 was deleted and 0.74 if
question 9 was deleted. Questions were clustered across three
themes including: student demographics, knowledge of the
H1N1 1918 influenza pandemic and infection control and
views on the history of medicine within the medical school
curriculum.
2Journal of Medical Education and Curricular Development
The questionnaire was formulated and completed within the
Qualtrics Experience Management Platform (Qualtrics
International Inc, Utah, U.S.). A full copy of the questionnaire
is included in Supplemental Material –Table 1 Copy of
Questionnaire.
Participants
All current medical students studying within a UK medical
school at the time of the study were eligible for inclusion. In
addition, final year students who graduated early to assist
with the coronavirus pandemic were also eligible. All year
groups were invited. No power calculation was performed for
estimation of sample size selected for the study as all UK
medical students were invited. Previous work in this area has
been unpowered but demonstrated thematic data saturation at
a low sample size.
16,17
Due to the outbreak of COVID-19, the survey was distrib-
uted via an online format only to comply with UK Government
regulations at the time. All responses collected were anonymous
and no personal identifiers were collected. Consent was gained
at the time of questionnaire completion.
Recruitment
Undergraduate administrators were contacted at all UK medical
schools with study details provided including study aims, a link
to the survey, a participant information leaflet and consent
form. A request was made for inclusion of the study within
student cascade emails. Given ethical concerns raised around
student overload during the coronavirus pandemic more
active recruitment strategies were not pursued. The survey
was open from the 18th of December 2020 to the 31st of
March 2021.
Statistical analyses
Descriptive statistics of population demographics including
medical school attended, type of course (graduate/undergradu-
ate) and year of study were performed using Microsoft Excel
(Microsoft Excel for Mac Version 16.48). Data on year of
study was normalised as percentage course completion to
allow better between group comparison, given differing course
length, with percentage course completion equivalent to year
of study divided by course length. Statistical analysis was per-
formed using SPSS statistical software (IBM SPSS Statistics
Version 27). Statistical comparison was undertaken for
knowledge-based questionnaires. Comparison was performed
based on key demographic features including graduate versus
undergraduate program, percentage course completion and pre-
vious exposure to history of medicine teaching. These were
selected to inform firstly against potential confounders but
then further to assess the effect of previous history of medicine
teaching exposure. Comparison of responses was performed
using a Chi-squared test. Where a value within a table was
less than five, Fishers exact tests were performed. A significance
value of P =<0.05 was used.
A grounded theory emergent coding thematic analysis was
undertaken on free text responses using Quirkos (Quirkos
(CADAS) for MacOS version 2.4.1). Coding was performed
by a single-reviewer following collation of free-text responses
and analysed independently of the demographic and
knowledge-based questions. Emergent themes were coded,
and a second look was performed to ensure all themes that
emerged were captured across the responses. Emergent
themes were assessed against a grounded theory framework
seeking to establish theory on the use of history of medicine
teaching within the medical school curricula. This method
was selected as it did not pre-suppose the views of the respon-
dents while still allowing these to be assessed against the project
aims.
Reporting
This study is reported in line with the Strengthening of the
Reporting of Observational Studies Epidemiology
(STROBE) Statement.
24
A copy of the STROBE statement
can be seen in Supplemental material STROBE checklist.
Table 1. Further analysis of question ‘what is the difference between an
epidemic and a pandemic?”(n =210).
Variable Correct
Answer
(n=)
Incorrect
Answer (n=)
Value P-Value
4-year
programme
Yes 35 1 22.850* 0.001
No 169 5S
% of the way
through the
Medicine
Course
100 18 0 31.544* 0.009
80 22 6
75 4 1
70 1 0
60 20 0
50 18 0
40 41 1
25 11 0
20 69 4
Previous
teaching on
history of
pandemics
Yes 71 0 215.185 0.001
No 133 6
Previous
teaching on the
1918 H1N1
Influenza
pandemic
Yes 33 0 213.163 0.001
No 171 6
Significant P-values are indicated in bold. Values marked by * indicate Fisher
Exact test was performed.
Jones et al 3
Funding
No funding was received for the completion of this project.
Results
Between 11
th
December 2020 and 31
st
March 2021 241
responses were collected and all students consented for their
data to be used in this study.
Medical demographics
237 respondents provided completed answers relating to their
medical school demographics. Responses were received from
8 medical schools. 4 responses were incomplete. 42 students
were on a 4 year degree, 146 students were on a 5 year degree
and 52 students were on a 6 year degree.
Figure 1 demonstrates the numbers of participants included
at each step of analysis. 17.8% of students were on a 4-year
graduate medical programme. No students who completed
the survey had recently graduated to help with the ongoing cor-
onavirus pandemic. Course length varied from 4 years to 6 years
with most students being on a 5-year programme (n =146).
Median year of study at time of completion of the study was
2 and majority of students were 20% of the way through their
medical degree (n =81).
Knowledge of the H1N1 1918 influenza pandemic and
infection control
Previous teaching
34% of respondents reported previous teaching on the history of
pandemics (71/210). Of the remaining 139 students that
answered no, 78% (108/139) displayed a positive stance to
inclusion of the history of pandemics within the curriculum.
Distribution of the themes generated from free-text responses
is shown in Figure 2.
Where reasons for a positive response were given, these
centred on the recent pandemic including “in light of recent
events”and “given the current COVID-19 pandemic”.
Additionally, 5 students reported it being beneficial in terms
of infection control and prevention. 10 students reported a
neutral response with terms including “maybe”,“not sure”and
“perhaps”.21/122 students’(9%) displayed a negative stance
to inclusion of the history of pandemics with 2 students expla-
nations surrounding content of medical school exams for
example, “…already have too much to remember. This would be
extra examinable content”.
33/210 (15%) of students reported specific teaching on the
1918 H1N1 Influenza Pandemic at Medical school and this
data is shown in Figure 3.
Of the remaining 177 students responding no, 62% (110/
177) displayed a positive desire to have this included within
the curriculum with 9 students commenting that it would be
useful from a public health perspective and 6 students mention-
ing COVID-19 in their answers. 15/167 (9%) of student’s
answers centred on themes of uncertainty on content “I don’t
know what it would entail so I don’t know if I would benefit…”
and “Depends on how they teach it and what its learning objectives
are”.Finally, 29/167 (17%) students showed a negative stance
with 3 students being grouped into the theme - curriculum
overload.
Knowledge on pandemics and infection control
Overall, knowledge was poor, with only 12/210 (5.7%) students
answering all 4 questions correctly and median number of cor-
rectly answered questions was 2. A full copy of the multiple
choice questions used to ascertain knowledge is included in
Supplemental Material –Table 1 Copy of Questionnaire.
97% (204/210) of students correctly identified the difference
between a pandemic and an epidemic. Students were more
likely to correctly answer if they had had previous teaching on
the history of pandemics (100% vs 96% P =0.001) (Table 1).
76/210 (36%) of students correctly identified all 3 methods
of transmission of influenza spread (close contact with infected
person, coughs and sneezes and contact with infected animals).
30/210 (14%) of students incorrectly identified that influenza
can be spread via blood transfusions and 36/210 (17%) of stu-
dents incorrectly identified that influenza can be spread via
sexual contact. No significant difference with previous teaching
was seen. However, students were more likely to correctly
answer how influenza can spread if they were closer to the
start of their degree (43% vs 56% P =0.009) (Table 2).
Limited knowledge on reduction of transmission in viral
pandemics was seen with only 53/210 (25%) of students cor-
rectly identifying all 7 methods (social distancing, covering
Figure 1. Number of students completing the questionnaire at each section.
The questionnaire is split broadly into three sections 1. Student
demographics 2. Knowledge of the H1N1 1918 influenza pandemic and
infection control 3. Views on the history of medicine in the medical school
curriculum. A full copy of the questionnaire is attached in the document titled
“Supplemental Material –Table 1 Copy of Questionnaire”.
4Journal of Medical Education and Curricular Development
Figure 2. Frequency of answers and themes generated from free text answers relating to the inclusion of the history of medicine at medical school.
Figure 3. Frequency of answers and themes generated from free text responses in relation to including the 1918 H1N1 influenza pandemic in the medical
school curriculum.
Jones et al 5
nose and mouth when coughing/sneezing, hand washing,
staying home, wearing protective clothing when in public
places, antiviral drugs and vaccinations). No significant differ-
ence was seen by year of medical school (P =0.195)
(Table 3). Students were more likely to answer correctly if
they had not had previous teaching on the history of pandemics
(21% vs 27%; p =0.013).
82/210 (39%) of students correctly identified treatment
options for influenza. Students were more likely to answer cor-
rectly if they were towards the start of their medical degree (P =
0.030) (Table 4). 44% of students with previous teaching on the
history of pandemics answered correctly compared to 37%
without (P =0.051) (Table 4).
History of medicine
Only 33% (63/190) of students reported that the history of
Medicine is taught at their medical school (Figure 4).
Of those reporting teaching over half (56% - 35/63) reported
this being via lectures with the remainder reporting being
taught by essays, problem-based learning, or student selected
components. 29% of comments were grouped around the
emergent theme of brief engagement with the topic including
“very limited amounts”,“very briefly”and “brief relevant points
at the start of a lecture”. Most content was coded around the
theme of generalised, “general epidemiology”,“pretty much every-
thing”,“a wide range of topics”. 12 students reported having
choice over the area that they study, and 6 students reported
learning the history of Medicine in relation to Anatomy. 4 stu-
dents reported pandemics being taught with one commenting
“a bit on famous pandemics like HIV, H1N1, Swine Flu”.
Additionally, only one student commented on the impact of
learning about the history of Medicine with regards to
current care: “what we can learn from our history to provide
more ethical care now”.
72% (137/190) of students were positive about the import-
ance of learning history of medicine as demonstrated in
Figure 5.
Only 15% (28/190) of students answered disagree. Those
with a positive response (87%) included themes such as
helping to guide future practice: “To better prepare students for
Table 2. Further analysis of question select all correct answers for how
influenza can be spread (n =210).
Variable Correct
Answer
n=
Incorrect
Answer n=
Value P-Value
4-year programme Yes 13 23 43.184* 0.072
No 63 111
% of the way
through the
Medicine Course
100 7 11 148.403* 0.048
80 10 22
75 2 2
70 0 1
60 9 11
50 4 14
40 17 25
25 4 7
20 23 50
Previous teaching
on history of
pandemics
Yes 24 47 50.520* 0.005
No 52 87
Previous teaching
on the 1918 H1N1
Influenza pandemic
Yes 11 22 45.925 0.035
No 65 112
Correct Answer is referring to all 3 methods of transmission being correctly
identified (close contact with infected person, coughs and sneezes and contact
with infected animals). Incorrect answer refers to all other combinations of
answers. Significant P-values are indicated in bold. Values marked by * indicate
Fisher Exact test was performed.
Table 3. Further analysis of question select all correct answers for how
influenza/viral pandemic can be prevented.
Variable Correct
Answer
n=
Incorrect
Answer n=
Value P-Value
4-year
programme
Yes 10 26 99.107* 0.107
No 43 131
% of the way
through the
Medicine
Course
100 2 16 379.882* 0.195
80 4 69
75 3 8
70 0 42
60 6 12
50 2 18
40 7 35
25 4 7
20 25 48
Previous
teaching on
history of
pandemics
Yes 15 56 103.846* 0.013
No 38 101
Previous
teaching on
the 1918 H1N1
Influenza
pandemic
Yes 8 25 97.207* 0.090
No 45 132
Correct Answer is referring to all 7 methods of being correctly identified (social
distancing, covering nose and mouth when coughing/sneezing, hand washing,
staying home, wearing protective clothing when in public places, antiviral drugs
and vaccinations). Incorrect answer refers to all other combinations of answers.
Significant P-values are indicated in bold. Values marked by * indicate Fisher
Exact test was performed.
6Journal of Medical Education and Curricular Development
potentially needing to work in pandemic conditions in the future”
and “History repeats itself so we must learn from it”. 24% of stu-
dents’responses were themed around mistake avoidance.
Additionally, one student commented, “I only know as much
as I do due to my essay title, but I think it would have been import-
ant for everyone…By learning history of Medicine, we can learn
from previous mistakes…”.
Overall, students were positive (79% 150/190) about the
benefit of learning around the H1N1 pandemic given the
Covid-19 pandemic. Only 7% of students answered strongly
disagree or somewhat disagree and the remainder (14%)
answering neither agree nor disagree.
52% (92/177) of students felt there was more they wanted to
be included within their course while 33% (65/177) felt there
wasn’t and 11% (20/117) were unsure. 94 students commented
on what they felt should be taught, the emergent themes for this
can be seen in Figure 6.
The majority (29% 27/94) of student’s responses centred on
history and in particular infectious disease history and develop-
ment of medical and surgical techniques (24/94). More specif-
ically, responses demonstrated key themes including providing
more information on how pandemics have been dealt with pre-
viously and how certain diseases in the developed world have
been eradicated over time. Ethics and culture was also a
common theme with a desire to learn the “…specific basis for
key ethno-cultural attitudes towards treatments…”,“…socio-
economic inequalities…” and “traditional medical practises…”.
A further theme that emerged centred on an understanding of
previous medical injustice with a desire to learn “…
Guatemalan STD trials as an example of malpractice”,“…
Racial bias…” and “Medicine around the world –we are not
all equally developed”.
Finally, students were asked on if they had any other com-
ments they wanted to add. A handful of students answered
with responses including “Being integrated and a natural part
of the course is important…because the history of medicine provides
context to modern medical practices…”.
Discussion
To our knowledge, this is the first known study assessing atti-
tudes and knowledge of UK medical students on the history of
Medicine in relation to historical pandemics. We present data
demonstrating that overall, students displayed a positive
stance to the inclusion of the history of Medicine in relation
to historical pandemics in the curriculum with only 34% of
respondents commenting that it was included. Knowledge on
pandemics and infection control was poor - only 5.7% of stu-
dents answered all questions correctly. Of the 72% of students
who had a positive stance on the importance of learning about
the history of Medicine, 87% of student’s responses were coded
into the theme “future practice”. Additionally, students were
positive (79%) about the benefit of learning about the H1N1
1918 Influenza pandemic given the current COVID-19
pandemic.
While the recent COVID-19 outbreak has led to an array of
questions surrounding medical education, such as the role of
medical students within a pandemic and effects on medical
education, it should perhaps also lead to a re-assessment of
the constitution of the medical curriculum.
14,15,22
Our exten-
sive literature search demonstrated that there are potential ben-
efits of teaching the history of Medicine to medical students –
not only the direct knowledge gained but also in terms of
context relating to historical perspectives as shown in 2012
with a history of Medicine seminar in an MD program.
25
Arguments have been made on the role of Medical history
for the doctor since at least 1904.
26
Despite this, there is little
literature assessing the role.
In 1948 Winston Churchill spoke to the commons stating
“Those who fail to learn from history are condemned to repeat
it”.
27
Throughout COVID-19, comparisons in how the pan-
demic was dealt with were made to the 1918 and 2009 influenza
pandemics given the significant impact on the population. Past
pandemics have often led to significant changes in public health
policies and healthcare systems. In 1918, the influenza
Table 4. Further analysis of question select all correct answers for how
influenza/viral pandemic can be treated?”
Variable Correct
Answer
n=
Incorrect
Answer n=
Value P-Value
4-year
programme
Yes 12 24 71.174* 0.027
No 70 104
% of the way
through the
Medicine
Course
100 6 12 259.811* 0.030
80 8 15
75 1 3
70 0 1
60 12 8
50 7 11
40 13 29
25 5 6
20 30 43
Previous
teaching on
history of
pandemics
Yes 31 40 67.681* 0.051
No 51 88
Previous
teaching on
the 1918 H1N1
Influenza
pandemic
Yes 15 18 67.602* 0.078
No 67 110
Correct Answer is referring to both methods of being correctly identified (bedrest
and antivirals). Incorrect answer refers to all other combinations of answers.
Significant P-values are indicated in bold. Values marked by * indicate Fisher
Exact test was performed.
Jones et al 7
pandemic led to significant improvements in disease surveil-
lance and vaccine development.
10
By understanding these
changes, it allows decision makers to make informed choices
about resource allocation and campaigns to reduce transmission
such as vaccine introduction. Epidemiologists have argued that
when comparing the 1918 and 2009 pandemics the earlier
implementation of social distancing and school closures in
1918 had a larger effect on fewer overall cases and improved
long term economic outcomes.
28
More specifically in terms of
the role of medical professionals, when comparing the 2009
pandemic to Covid-19, there are striking similarities in
morbidity and the physiological effect of the viruses and the
number of ICU admissions.
21
In 2009, hospitals unfortunately
had difficulty coping with the numbers of admissions, staffing
levels, antiviral treatment, and supply of ventilation equip-
ment.
29
In 2020, unfortunately the same happened again with
hospital staff struggling to get hold of vital personal protective
equipment and hospitals struggling to cope with the number of
admissions and the demand on ventilators.
30
Thus, posing the
question, if medical professionals had a greater understanding
of previous pandemics, could we have potentially prevented
erroneous decisions from being made?
Figure 4. Frequency of answers and themes generated from free text responses in relation to whether the history of medicine in included in the curriculum, what
this includes and how it is taught.
8Journal of Medical Education and Curricular Development
More generally, within the UK, the incorporation of history
of Medicine within the undergraduate curriculum is haphazard
and guided by the force of interested personalities as demon-
strated by our results. The situation is no different in the post-
graduate context. With an American study of anaesthetic
residency programs showing a low rate of inclusion of the
history of anaesthesia.
31
Even within public health domains,
the process of integration of the history of medicine into the
curriculum has been described as infiltrative rather than
overt.
26
The advantages of including the history of medicine
of pandemics in the curriculum are clearly understood by the
students we assessed with the majority of students demonstrat-
ing a positive stance on the inclusion. This fits in with a popular
approach used by medical schools which focuses less on lectures
and more on a humanistic and student-centred approach to
guide topics which has been demonstrated to aid long-term
memory formation and deepen understanding.
32-34
This study is the first to suggest the potential wider benefit
of contextualising learning within a history of medicine frame-
work in relation to historical pandemics. Our results highlight
that students are keen to learn from the past and include the
history of Medicine in the curriculum, deeming that it would
deepen their understanding of culturally important topics.
Additionally, making mental connections is critical to our
learning and context matters. Healthcare is a developing field
and students need to be able to identify context and learn
from this to be effective clinicians.
35
However, students raised
concerns which were rightly centred on the crowding of the cur-
riculum. Medical degrees are re-owned for the enormous
amount of content which often leaves students having to mem-
orise facts and lacking a deeper understanding of the topic and
problem solving skills.
36,37
Stress and burnout is unfortunately
common in the UK with 1/3 of doctors being affected.
38
Medical school is demanding with students being expected to
memories enormous amounts of content, cope with everyday
stress and deal with traumatic and difficult situations on a not
uncommon basis. The effect of not being able to cope and
process crises not only has a potential detrimental effect on stu-
dents health but also has been suggested to impede memory
formation and performance and may play a role in reducing
cognitive empathy.
39,40
By institutions developing an under-
standing that factors such as stress can have a negative impact
Figure 5. Frequency of answers and themes generated from free text responses in relation to the statement: The history of medicine is important to learn about
at medical school.
Jones et al 9
on not only students but also memory formation and reduce the
likelihood of positive clinician-patient interactions and addres-
sing these areas where possible –this can help to ensure that
future doctors are greater prepared for the challenges that
they may face in their careers.
41
The effectiveness of previous teaching on history of pan-
demics in answering some of our knowledge-based questions
suggests that a history of medicine-based pedagogy may
increase interest, incorporate historical lessons, and facilitate
learning on modern medical practice helping to ensure that
future doctors feel better prepared for situations in their prac-
tice. This is of a high degree of relevance with society turning
to previous pandemics for guidance and the similarities drawn
between the current COVID-19 and the 1918 and 2009
Influenza pandemics epidemiological curves.
5-7
As other
researchers have suggested, teaching medical students positive
coping mechanisms and ways to improve their quality of life
during medical school can have a huge impact on preparing
them for future challenges in their careers.
42,43
Limitations of study
Despite the findings of this study, there are several limitations
including that of sample size. At the time of completing this
study, there were a total of 54,00 medical students in the UK
divided between 41 medical schools. The questionnaire was
distributed to all UK medical schools to allow for maximum
participation in our study. These results represent a sampling
of 20% of medical schools within the UK and include students
from both non-graduate and graduate entry programmes and at
all stages in their medical degree. Thus while reduced, the
sample size does demonstrate a good cross-section of the
medical school cohort. This study only captures a cross sectional
population at a time when pandemics are in active memory.
Additionally, the data may be skewed by reporting bias with
students who are more interested in the topic being more
likely to answer. There was also an element of weighted report-
ing favouring certain medical schools thus decreasing the gen-
eralisability of our results.
Figure 6. Graph displaying number of students who said yes to including additional topics in the medical school curriculum with regards to the history of
medicine divided into coding categories.
10 Journal of Medical Education and Curricular Development
Suggestions for implementation
Recent events and students’expectations as presented in this
study, suggest the need to incorporate pandemics and pandemic
management into the medical school curriculum. Our findings
suggest the need to include incorporation of the development of
key medical advances within learning about these advances to
contextualise the intervention and therefore aid memory forma-
tion deepening mental connections. In terms of the practical-
ities of this, over half of students felt it would be beneficial to
include in lectures versus the remaining half preferring the
history of medicine such as pandemics be better incorporated
into other aspects of their learning eg, case-based sessions.
There may be a wider need to train medical educations in a nar-
rative approach to teaching to better incorporate the history of
medicine into the curriculum. Additionally, it may be useful for
a future study to invite staff from UK medical schools who are
involved in the current curriculum to also answer the survey and
assess their views on curriculum development and the inclusion
of the history of pandemics in the curriculum.
Conclusions
To conclude, our evidence suggests that there are significant
gaps in medical students understanding of pandemics and
infection control with the majority of students displaying a
positive stance to the inclusion of the history of pandemics in
the medical school curriculum. Recent events and feedback
from students suggest the need to incorporate pandemics and
pandemic management in the curriculum with the majority of
students favouring including it in lectures. Our findings indi-
cate that such teaching may improve understanding of key con-
cepts within infectious disease and students appreciate the value
of learning about the history of pandemics. It is vital that
today’s medical students and therefore tomorrow’s doctors
are taught about such important historical events to ensure
that they are as well prepared as they can be when history
repeats itself.
Acknowledgments
Not applicable
Supplemental material
Supplemental material for this article is available online.
Ethics approval and consent to participate
Full ethical approval was gained from the Biomedical and
Scientific Ethics Committee (BSREC) from the University of
Warwick for this project.
All methods were carried out in accordance to relevant
guidelines and regulations. All experimental protocols were
approved by the Biomedical and Scientific Ethics Committee
at the University of Warwick. GDPR standards were adhered
to throughout the study in line with the Data Protection Act
2018 and the GDPR. Informed consent was obtained from
all subjects and/or their legal guardian(s).
Consent for publication
Not applicable
Availability of data and materials
The datasets used/or analysed during the current study are
available from the corresponding author on reasonable request
Competing interests
The authors declare that they have no competing interests.
Authors’contributions
All authors contributed to the design and achieving ethical
approval for this study including design of the questionnaire
sent out to universities which included the participant
consent form. MJ analysed the data with the support of JO.
All authors contributed to the final manuscript and all
authors read and approved the final manuscript for consider-
ation of publication.
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